Children With ADHD Diagnoses and Adverse Childhood Experiences in A Public Mental Health System

Children who have experienced adverse childhood experiences (ACEs) often present with emotional and behavioral characteristics that overlap with attention-deficit/hyperactivity disorder (ADHD), yet it remains unclear which trauma-related needs uniquely distinguish children with and without ACEs. Using data from 10,869 children receiving services in a statewide public mental health system, we compared children with ADHD and ACEs (ADHD + ACE) ( n = 6,024) to those without ACEs (ADHD-only) ( n = 4,845) on trauma-related emotional, behavioral, and risk behavior domains from the Child and Adolescent Needs and Strengths (CANS) assessment. Attachment difficulties, traumatic grief/separation, depression, oppositional behavior, self-mutilation, danger to others, poor judgment, and sexually reactive behavior independently predicted greater odds of ADHD + ACE classification. In contrast, attention/concentration difficulties and behavioral regressions were negatively associated with ADHD + ACE status, suggesting that when trauma-related emotional and risk behavior needs are jointly considered, ADHD-only profiles may be characterized by narrower attentional and behavioral regression concerns. Older age was also associated with higher likelihood of ADHD + ACE classification. Findings highlight a trauma-related dysregulation phenotype among children with ADHD + ACE and underscore the importance of trauma-responsive, developmentally informed, and dimensional assessment in mental health systems, rather than relying solely on attention when conceptualizing ADHD.